Choice Psychiatric Healthcare | Disability Assessment Form

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Disability Assessment

World Health Organization Disability Assessment Schedule 2.0

First and Last Name *

Email *

Date of Birth

This questionnaire asks about difficulties due to health/mental health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions thinking about how much difficulty you had doing the following activities. For each question, please chose one response.

In the last 30 days, how much difficulty did you have in: UNDERSTANDING & COMMUNICATING

1. Concentrating on doing something for ten minutes?

None

Mild

Moderate

Servere

Extreme or can not do

2. Remembering to do important things?

None

Mild

Moderate

Severe

Extreme or can not do

3. Analyzing and finding solutions to problems in day-to-day life?

None

Mild

Moderate

Severe

Extreme or can not do

4. Learning a new task, for example, learning how to get to a new place?

None

Mild

Moderate

Severe

Extreme or can not do

5. Generally understanding what people say?

None

Mild

Moderate

Severe

Extreme or can not do

6. Starting and maintaining a conversation?

None

Mild

Moderate

Severe

Extreme or can not do

In the last 30 days, how much difficulty did you have in: GETTING AROUND

1 - Standing for long periods, such as 30 minutes?

None

Mild

Moderate

Severe

Extreme or can not do

2. Standing up from sitting down?

None

Mild

Moderate

Severe

Extreme or can not do

3 - Moving around inside your home?

None

Mild

Moderate

Severe

Extreme or can not do

4. Getting out of your home?

None

Mild

Moderate

Severe

Extreme or can not do

5. Walking a long distance, such as a kilometer (or equivalent)?

None

Mild

Moderate

Severe

Extreme or can not do

In the last 30 days, how much difficulty did you have in: SELF CARE

1. Dealing with people you do not know?

None

Mild

Moderate

Severe

Extreme or can not do

2. Maintaining a friendship?

None

Mild

Moderate

Severe

Extreme or can not do

3. Getting along with people who are close to you?

None

Mild

Moderate

Severe

Extreme or can not do

4. Making new friends?

None

Mild

Moderate

Severe

Extreme or can not do

5. Sexual activities?

None

Mild

Moderate

Severe

Extreme or can not do

In the last 30 days, how much difficulty did you have in: LIFE ACTIVITIES: HOUSEHOLD

1. Taking care of your household responsibilities?

None

Mild

Moderate

Severe

Extreme or can not do

2. Doing most important household tasks well?

None

Mild

Moderate

Severe

Extreme or can not do

3. Getting all of the household work done that you needed to do?

None

Mild

Moderate

Severe

Extreme or can not do

4. Getting your household work done as quickly as needed?

None

Mild

Moderate

Severe

Extreme or can not do

In the last 30 days, how much difficulty did you have in: LIFE ACTIVITIES: SCHOOL / WORK

If you work (paid, non-paid, self-employed) or go to school, complete questions 5.5–5.8, below. Otherwise, skip to 6.1.

5. Your day-to-day work/school?

None

Mild

Moderate

Severe

Extreme or can not do

6. Doing your most important work/school tasks well?

None

Mild

Moderate

Severe

Extreme or can not do

7. Getting all of the work done that you need to do?

None

Mild

Moderate

Severe

Extreme or can not do

8. Getting your work done as quickly as needed?

None

Mild

Moderate

Severe

Extreme or can not do

In the last 30 days, how much difficulty did you have in: PARTICIPATION IN SOCIETY

1. How much of a problem did you have in joining in community activities (for example, festivities, religious, or other activities) in the same way as anyone else can?

None

Mild

Moderate

Severe

Extreme or can not do

2. How much of a problem did you have because of barriers or hindrances around you?

None

Mild

Moderate

Severe

Extreme or can not do

3. How much of a problem did you have living with dignity because of the attitudes and actions of others?

None

Mild

Moderate

Severe

Extreme or can not do

Radio 61uuh4. How much time did you spend on your health condition or its consequences?

None

Mild

Moderate

Severe

Extreme or can not do

5. How much have you been emotionally affected by your health condition?

None

Mild

Moderate

Severe

Extreme or can not do

6. How much has your health been a drain on the financial resources of you or your family?

None

Mild

Moderate

Severe

Extreme or can not do

7. How much of a problem did your family have because of your health problems?

None

Mild

Moderate

Severe

Extreme or can not do

8. How much of a problem did you have in doing things by yourself for relaxation or pleasure?

None

Mild

Moderate

Severe

Extreme or can not do

Signature

Date

Formerly Women’s Psychiatric

Healthcare, LLC

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HOME ABOUT

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Formerly Women’s Psychiatric Healthcare, LLC

NAVIGATE

HOME

ABOUT

SESSION TYPES

SCHEDULING

BILLING

POLICIES

FORMS

BALANCE LAB

RELATIONAL STUDIO

RAINBOW ROOM

RESOURCES

TESTIMONIES

CONTACT/VIDEO

173 Belmont Ave, Doylestown, PA 18901, USA

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